<?php 
/**
 * @version			$Id: default_step3.php 6 2010-07-22 10:04:21Z lowcosta@gmail.com $
 * @author			Richard Asp
 * @package			Joomla
 * @subpackage		gnudoor
 * @copyright		(C) 2010 gnudoor LLC
 * @license      GNU/GPL, see LICENSE.php
 * Joomla! is free software. This version may have been modified pursuant
 * to the GNU General Public License, and as distributed it includes or
 * is derivative of works licensed under the GNU General Public License or
 * other free or open source software licenses.
 * See COPYRIGHT.php for copyright notices and details.
 */

defined( '_JEXEC' ) or die( 'Restricted access' );
// JHTML::_('script', 'datetimepicker_css.js', 'components/com_gnudoor/assets/js/');
JHTML::_('stylesheet', 'form.css','components/com_gnudoor/assets/css/');
JHTML::_('stylesheet', 'rfnet.css','components/com_gnudoor/assets/css/');
$calgif = JHTML::image('components/com_gnudoor/assets/img/cal.gif','');
// JHTML::_('script', 'simpleCart.js', 'components/com_gnudoor/assets/js/');
// JHTMLBehavior::formvalidation();
?>
<div id="form_container" class="myform">

		<form id="form_253539" name="helpForm" class="form-validate"  method="post" action="#" onSubmit="return myValidate(this);">
<fieldset>
	   <legend>Escrow funds for <?php echo $this->titles[formProvider]; ?>
		</legend>

  <table>
    <caption class="cap">
    </caption>
    <tr>
      <td class="bolder"><label class="description" for="name"><?php echo $this->titles[formName]; ?></label></td>
      <td class="info"><?php echo $this->row->name; ?></td>
    </tr>
    <tr>
      <td class="bolder"><label class="description" for="dateDue"><?php echo $this->titles[formDueDate]; ?></label></td>
      <td class="info"><?php echo $this->row->dateDue; ?></td>
      
    </tr>
    <tr>
    	<td><label class="description"><?php echo $this->titles[formProvider]; ?></label></td>
    	<td><?php echo $this->pname->providerName; ?></td>
    </tr>
    <tr>
      
      <td colspan="2" class="info">
<table width="95%" border="1" cellspacing="1" cellpadding="2">
  <tr>
    <th width="23%" scope="row">Name on Credit Card </th>
    <td width="77%"><input type="text" name="CCName" /></td>
  </tr>
  <tr>
    <th scope="row">Credit Card Type </th>
    <td><input name="radiobutton" type="radio" value="v" />
    visa 
      <input name="radiobutton" type="radio" value="mc" />
    master card 
    <input name="radiobutton" type="radio" value="ae" />
    amex</td>
  </tr>
  <tr>
    <th scope="row">Card Number </th>
    <td><input type="text" name="CCNumber" /></td>
  </tr>
  <tr>
    <th scope="row">Expiration Date </th>
    <td>Month
      <select name="ExMonth">
        <option value="1">01</option>
        <option value="2">02</option>
        <option value="3">03</option>
        <option value="4">04</option>
        <option value="5">05</option>
        <option value="6">06</option>
        <option value="7">07</option>
        <option value="8">08</option>
        <option value="9">09</option>
        <option value="10">10</option>
        <option value="11">11</option>
        <option value="12">12</option>
      </select>
     Year
     <select name="ExYear">
       <option value="2010">2010</option>
       <option value="2011">2011</option>
       <option value="2012">2012</option>
       <option value="2013">2013</option>
     </select>
    </td>
  </tr>
  <tr>
    <th scope="row">Amount</th>
    <td><input type="text" name="amount" /></td>
  </tr>
</table>


      </td>
    </tr>
  </table>
<input type="hidden" name="option" value="com_gnudoor" />
<input type="hidden" name="controller" value="pay" />
<input type="hidden" name="task" value="display" />
<input type="hidden" name="id" value="<?php echo $this->row->id; ?>" />
<input type="hidden" name="status" value="4" />



<input id="saveForm" class="submitbutton" onclick="javascript: submithelpbutton('save')" type="submit" name="submit" value="Update" />
<input id="cancelForm" class="submitbutton" onclick="javascript: submithelpbutton('cancel')" type="submit" name="cancel" value="Back" />
  
</fieldset>
</form>



</div>


